Case Manager

2 weeks ago


Johannesburg, South Africa Edge Executives Full time
Key Responsibilities:
  1. Case Management:
    • Manage hospital admissions by reviewing the appropriateness of care and ensuring all admissions are clinically warranted.
    • Conduct pre-admission, admission, and discharge planning, including monitoring length of stay and level of care to ensure it aligns with scheme rules and clinical guidelines.
    • Coordinate with healthcare providers to ensure the most efficient and cost-effective care is delivered to patients.
  2. Clinical Assessments and Authorisations:
    • Perform clinical assessments based on patient medical records, treatment plans, and physician reports.
    • Approve or recommend alternative care options based on medical necessity, ensuring alignment with clinical guidelines.
    • Authorise hospital admissions, procedures, and specialist treatments in line with policy and clinical protocols.
  3. Collaboration with Providers:
    • Communicate regularly with healthcare providers (hospitals, doctors, and allied healthcare professionals) to review patient progress and treatment plans.
    • Facilitate case conferences between healthcare providers when necessary to improve patient outcomes.
    • Liaise with multi-disciplinary teams to ensure integrated patient care and support appropriate care pathways.
  4. Cost and Resource Management:
    • Monitor and manage the cost of hospitalisation, treatment, and post-discharge care in alignment with the medical aid schemes financial goals.
    • Identify potential cost-saving measures while ensuring patients receive high-quality care.
    • Monitor adherence to length of stay targets, care levels, and use of hospital resources to avoid unnecessary hospital stays and over-treatment.
  5. Risk and Compliance Management:
    • Ensure compliance with all clinical and regulatory guidelines, medical aid scheme rules, and hospital policies.
    • Identify and manage clinical risks by implementing interventions that align with the scheme's objectives.
    • Ensure accurate and timely documentation of all case management activities and maintain comprehensive records for auditing and reporting purposes.
  6. Reporting and Documentation:
    • Prepare and maintain detailed case reports for each patient, documenting clinical interventions, hospital admissions, length of stay, and discharge planning.
    • Provide regular updates to management on key case management metrics, including costs, compliance, and patient outcomes.
Key Skills & Competencies:
  • Clinical Knowledge: Deep understanding of hospital care, treatment protocols, and patient care pathways, especially in ICU, surgical, and medical ward settings.
  • Decision-Making: Ability to assess clinical cases and make informed decisions about patient care and cost containment.
  • Communication Skills: Excellent verbal and written communication skills for liaising with healthcare providers, patients, and medical aid administrators.
  • Collaboration: Strong ability to work with multi-disciplinary teams to ensure integrated and coordinated patient care.
  • Organisational Skills: Effective time management and organisational skills to manage multiple cases simultaneously.
  • Analytical Skills: Ability to analyse clinical data, treatment outcomes, and resource usage to provide insights and recommendations.
Minimum Requirements:
  • Education: Registered Nurse or Healthcare Professional with relevant clinical qualifications
  • Professional Membership: Registered with the South African Nursing Council (SANC) or relevant professional body
  • Experience: Minimum of 3-5 years of clinical experience in a hospital environment, with at least 2 years of experience in case management or managed care
  • Skills: Proficiency in clinical assessments, hospital billing, and discharge planning. Understanding of healthcare systems and regulations.

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